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Improving the Presumptive Disability Decision-Making Process for Veterans
IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS
Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans
Board on Military and Veterans Health
Jonathan M. Samet and Catherine C. Bodurow, Editors
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Improving the Presumptive Disability Decision-Making Process for Veterans
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. V101 (93) P-2136 between the National Academy of Sciences and United States Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-10730-3
International Standard Book Number-10: 0-309-10730-X
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2008 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2008. Improving the presumptive disability decision-making process for veterans. Washington, DC: The National Academies Press.
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Improving the Presumptive Disability Decision-Making Process for Veterans
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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Improving the Presumptive Disability Decision-Making Process for Veterans
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Improving the Presumptive Disability Decision-Making Process for Veterans
COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS
JONATHAN M. SAMET (Chair), Professor and Chair,
Department of Epidemiology,
Jacob I. and Irene B. Fabrikant Professor in Health, Risk, and Society,
Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
MARGARET A. BERGER, Suzanne J. and Norman Miles Professor of Law,
Brooklyn Law School, NY
KIRSTEN BIBBINS-DOMINGO, Assistant Professor of Medicine and of Epidemiology, Biostatistics,
University of California, San Francisco
ERIC G. BING, Endowed Professor of Global Health and HIV,
Charles R. Drew University of Medicine and Science, Los Angeles, CA
BERNARD D. GOLDSTEIN, Professor of Environmental and Occupational Health,
Graduate School of Public Health, University of Pittsburgh, PA
GUY H. McMICHAEL III, President,
GHM Consulting, Washington, DC
JOHN R. MULHAUSEN, Director,
Corporate Safety and Industrial Hygiene, 3M Company, St. Paul, MN
RICHARD P. SCHEINES, Professor and Head,
Department of Philosophy, Carnegie Mellon University, Pittsburgh, PA
KENNETH R. STILL, President and Scientific Director,
Occupational Toxicology Associates, Inc., Hillsboro, OR
DUNCAN C. THOMAS, Verna Richter Chair in Cancer Research, Professor, and Director,
Biostatistics Division, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
SVERRE VEDAL, Professor,
Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health and Community Medicine, Seattle
ALLEN J. WILCOX, Senior Investigator,
Epidemiology Branch, National Institute of Environmental Health Sciences, and
Editor-in-Chief of Epidemiology,
Durham, NC
SCOTT L. ZEGER, Frank Hurley-Catharine Dorrier Professor and Chair,
Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
LAUREN ZEISE, Chief,
Reproductive and Cancer Hazard Assessment Branch, Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, Oakland
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Improving the Presumptive Disability Decision-Making Process for Veterans
Volunteer Scientific Consultant
MELISSA McDIARMID, Professor of Medicine,
Occupational Health Program, University of Maryland School of Medicine, Baltimore
Consultant
ROBERT J. EPLEY, Independent Consultant,
Waxhaw, NC
Staff
CATHERINE BODUROW, Study Director
MORGAN A. FORD, Program Officer (May-August 2007)
LESLIE SIM, Program Officer (February-May 2006)
ALICE VOROSMARTI, Research Associate (May-August 2007)
CARA JAMES, Research Associate (June 2006-May 2007)
ANISHA DHARSHI, Research Associate (June 2006-January 2007)
KRISTEN BUTLER, Research Assistant (March-July 2007)
KRISTEN GILBERTSON, Research Assistant (February-July 2006)
JON Q. SANDERS, Program Associate (March 2006-May 2007)
REINE Y. HOMAWOO, Senior Program Assistant (May-August 2007)
VERA DIAZ, Intern (February-April 2007)
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BOARD ON MILITARY AND VETERANS HEALTH
ROBERT B. WALLACE (Chair), Professor of Epidemiology and Internal Medicine, and Director,
Center on Aging, College of Public Health, University of Iowa, Iowa City
GEORGE K. ANDERSON, Executive Director,
Association of Military Surgeons in the United States, Bethesda, MD
MICHAEL S. ASCHER, Senior Medical Advisor,
Defense Biology Biosciences Directorate, Lawrence Livermore National Laboratory, Livermore, CA
ARTHUR J. BARSKY, Professor of Psychiatry,
Harvard Medical School, and
Director of Psychiatric Research,
Brigham and Women’s Hospital, Boston, MA
DIANA D. CARDENAS, Professor and Chair,
Department of Rehabilitation Medicine, University of Miami, FL
LINDA D. COWAN, Professor,
University of Oklahoma College of Public Health, Oklahoma City
TIMOTHY R. GERRITY, Senior Partner,
Noventus Medical, Worcester, MA
KATHERINE L. HEILPERN, Acting Chair,
Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA
MYRON M. LEVINE, Head,
Division of Geographic Medicine, and
Director,
Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
SUSAN H. MATHER,
Department of Veterans Affairs (Retired), Bowie, MD
MATTHEW L. PUGLISI, Director,
Business Development, Aptima, Inc., Washington, DC
PHYLLIS W. SHARPS, Professor and Director,
Master’s Program, Johns Hopkins University School of Nursing, Baltimore, MD
ERNEST T. TAKAFUJI, Director,
Office of Biodefense Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD
Board Staff
FREDERICK ERDTMANN, Director
PAMELA RAMEY-McCRAY, Administrative Assistant
ANDREA COHEN, Financial Associate
IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Dan G. Blazer, Duke University Medical Center
Mark R. Cullen, Yale University School of Medicine
Lynn R. Goldman, Johns Hopkins Bloomberg School of Public Health
Steven N. Goodman, Johns Hopkins University School of Medicine
Robert F. Herrick, Harvard School of Public Health
Susan H. Mather, Department of Veterans Affairs (Retired)
Francis L. O’Donnell, Department of Defense’s Force Health Protection and Readiness Programs
Louise M. Ryan, Harvard School of Public Health
Patrick Ryan, PricewaterhouseCoopers
David A. Savitz, Mount Sinai School of Medicine
Harold C. Sox, American College of Physicians and Internal Medicine
Michael A. Stoto, Georgetown University
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Improving the Presumptive Disability Decision-Making Process for Veterans
Judith P. Swazey, The Acadia Institute
Joseph Thompson, Aequus, Inc.
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Gilbert S. Omenn, University of Michigan Medical School, and Willard G. Manning, University of Chicago. Appointed by the National Research Council and Institute of Medicine, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Improving the Presumptive Disability Decision-Making Process for Veterans
Preface
This committee, the Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans (Committee), was charged with describing the current process for how presumptive decisions are made for veterans who have health conditions arising from military service and with proposing a scientific framework for making such presumptive decisions in the future. Although an individual veteran can establish a direct service connection for an illness, the needed information on the responsible exposure received during military service may be unavailable or incomplete. Additionally, there may be scientific uncertainty as to whether the exposure is known to cause the health condition. To ensure that veterans are compensated when information for direct service connection is needed but unavailable, Congress or the Secretary of the Department of Veterans Affairs (VA) can decide to service connect entire groups of veterans for specific health conditions due to exposures received during service. This decision to compensate particular groups of veterans is called a presumptive disability service-connection decision or, simply, a presumption. A presumption may address unavailable or incomplete information on exposure or gaps in the evidence as to whether the exposure increases risk for the health condition.
Each veteran identified as eligible for coverage under a presumptive decision will have a separate, individual disability rating conducted by the VA and will be eligible for disability compensation based on the nature and severity of the health condition. That is, the presumptive disability service-connection decision is separate from the rating evaluation and compensation process.
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9-1
Hypothetical Example of Risks from Multiple Causal Exposures,
209
9-2
Hypothetical PAFs Due to Smoking and Military Exposure,
210
9-3
True and False Positive and Negative Rates,
215
9-4
Comparing Sensitivity and Specificity of Two Hypothetical Sets of Compensation Criteria,
216
9-5
Hypothetical Scenario 1: PPV When AF = 50 Percent,
217
9-6
Hypothetical Scenario 2: PPV When AF = 9 Percent,
217
9-7
Hypothetical Scenario 3: PPV When AF = 2 Percent,
218
10-1
Timeline for Medical Surveillance and Exposure Data Collection,
242
10-2
Service-Specific Databases for Exposure,
257
10-3
Summary of VET Registry Projects,
267
10-4
National Academies’ and VA Medical Monographs on Veterans’ Health by Theater or Exposure,
268
10-5
VA Health Registries,
274
FIGURES
GS-1
Proposed framework for future presumptive disability decision-making process for veterans,
4
S-1
Roles of the participants involved in the presumptive disability decision-making process for veterans,
11
S-2
Proposed framework for future presumptive disability decision-making process for veterans,
17
3-1
Roles of the participants involved in the presumptive disability decision-making process for veterans,
53
6-1
Information gathering and its use in making general and specific compensation decisions,
139
7-1
Causal and spurious associations,
158
7-2
Scenario for causation without association,
158
7-3
The power of randomization,
161
7-4
Age as a confounder,
163
7-5
Unmeasured confounders,
163
7-6
TV and obesity,
163
7-7
Instrumental variable,
165
7-8
Rothman’s sufficient component causes model,
167
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8-1
Hypothetical illustrations,
179
8-2
Focusing on unmeasured confounders/covariates, or other sources of spurious association from bias,
180
8-3
IARC evaluation scheme,
184
8-4
Example posterior for Sufficient,
190
8-5
Example posterior for Equipoise and Above,
191
8-6
Example posterior for Below Equipoise,
192
8-7
Example posterior for Against,
193
9-1
Example of ROC curves,
219
9-2
“Economically rational” compensation plan, based on the attributable fraction,
225
9-3
Complete compensation (100 percent) for all exposed persons with disease, regardless of attributable fraction,
225
9-4
Complete compensation for all exposed persons only when attributable fraction is 50 percent or more,
226
9-5
Complete compensation for an AF of 50 percent or more, plus graduated compensation below 50 percent,
227
9-6
A rational process for determining veterans’ compensation,
228
10-1
Timeline for medical surveillance and exposure data collection,
241
10-2
DoD’s deployment health surveillance elements,
256
10-3
National Defense Occupational and Environmental Health Readiness System (DOEHRS),
258
12-1
Proposed framework for future presumptive disability decision-making process for veterans,
311
BOXES
3-1
Representatives at Each Tier of VA’s Internal Review of NAS Reports,
59
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Acronyms and Abbreviations
ACB Army Classification Battery
ACES-EM Automated Civil Engineering System-Environmental Management
ACHRE Advisory Committee on Human Radiation Experiments
ADA American Diabetes Association
AEC Atomic Energy Commission
AF Attributable fraction
AF-EMIS Air Force Environmental Management Information System
AFCESA Air Force Civil Engineer Support Agency
AFHLTA Armed Forces Health Longitudinal Technology Application
AFHS Air Force Health Study
AFHSC Armed Forces Health Surveillance Center
AHA American Heart Association
AHLTA Armed Forces Health Longitudinal Technology Application
AhR Aryl hydrocarbon receptor
AIDS Acquired immunodeficiency syndrome
AIS Automated information systems
ALS Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
AML Acute myelogenous leukemia
ANG Air National Guard
ANLL Acute non-lymphocytic leukemia
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APIMS Air Program Information Management System
AS Assigned share
ASTM American Society for Testing and Materials
ATSDR Agency for Toxic Substances and Disease Registry
BEIR Biological Effects of Ionizing Radiation
BMI Body mass index
C&P Service Compensation and Pension Service
CCB Configuration Control Board
CCS Command Core System (Air Force)
CDC Centers for Disease Control and Prevention
CDVA Commonwealth Department of Veterans’ Affairs
CERHR Center for the Evaluation of Risks to Human Reproduction
CES-D Centers for Epidemiological Studies-Depression Scale
CFR Code of Federal Regulations
CHD Coronary heart disease
CHF Congestive heart failure
CHPPM Center for Health Promotion and Preventive Medicine (Army)
CI Confidence interval
CIA Central Intelligence Agency
CIRRPC Committee on Interagency Radiation Research and Policy Coordination
CLL Chronic lymphocytic leukemia
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CRDP Concurrent Retirement and Disability Payments
CRS Congressional Research Service
CRSC Combat-Related Special Compensation
CSM Cerebrospinal malformation
CSP Cooperative Studies Program
CVD Cardiovascular disease
DALY Disability-adjusted life year
DCI SCI Director of Central Intelligence Sensitive Compartmented Information Programs
DECC-D Defense Enterprise Computing Center-Detachment
DHHS Department of Health and Human Services
DISA Defense Information Systems Agency
DMDC Defense Manpower Data Center
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DMSS Defense Medical Surveillance System
DNBI Disease and nonbattle injury
DoA Department of the Army
DoD Department of Defense
DoDI Department of Defense Instruction
DOE Department of Energy
DOEHRS Defense Occupational and Environmental Health Readiness System
DoL Department of Labor
DSM-III-R Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised
DTAS Defense Theater Accountability Software
EA Exposure Assessment
EAR Excess absolute risk
EEOICPA Energy Employees Occupational Illness Compensation Program Act
EESOH-MIS Enterprise Environmental Safety and Occupational Health-Management Information System
EO Executive Order
EPA Environmental Protection Agency
EPCRA Emergency Planning and Community Right-to-Know Act
ERIC Epidemiologic Research and Information Center
ERR Excess relative risk
FECA Federal Employees’ Compensation Act
FERS Federal Employees Retirement System
FHIE Federal Health Information Exchange
FHP Force Health Protection
fMRI Functional magnetic resonance imaging
FN False negative
FNR False negative rate
FOUO For official use only
FP False positive
FPR False positive rate
FR Federal Register
FY Fiscal Year
GAF Global Assessment of Functioning
GAO Government Accountability Office
GBD General birth defect
GBS Guillain-Barre syndrome
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GPS Global Positioning System
GT test General Technical test
GW Gulf War
Gy Gray (measure of dose of irradiation)
HART Health Assessment Review Tool
HCFA Health Care Financing Administration
HEW U.S. Department of Health, Education, and Welfare
HHIM Health Hazard Information Module
HIV Human immunodeficiency virus
HMMS Hazardous Materials Management System
HUS Hemolytic-uremic syndrome
IARC International Agency for Research on Cancer
ICD International Classification of Diseases
IH Industrial hygiene
IHIMS Industrial Hygiene Information Management System (Navy)
IOM Institute of Medicine
IQ Intelligence quotient
IREP Interactive RadioEpidemiological Program
IU Individual unemployability
LIMDIS Limited Dissemination
LMF Lovelace Medical Foundation
MDS Myelodysplastic syndrome
MFUA Medical Follow-up Agency
MMPI Minnesota Multiphasic Personality Inventory
MOA Memorandum of Agreement
MOS Military occupational specialty
MRI Magnetic resonance imaging
MS Multiple sclerosis
MTF Military Treatment Facility
NAS National Academy of Sciences
NCEH National Center for Environmental Health
NCHS National Center for Health Statistics
NCI National Cancer Institute
NEHC Navy Environmental Health Center
NESHAP National Emission Standards for Hazardous Air Pollutants
NHANES National Health and Nutrition Examination Survey
NHL Non-Hodgkin’s lymphoma
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NHLBI National Heart, Lung, and Blood Institute
NHS Nurses Health Study
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
NOCONTRACT Not releasable to contractors
NOED Navy Occupational Exposure Database
NOFORN Not releasable to foreign nationals
NPV Negative predictive value
NRC National Research Council
NTP National Toxicology Program
NTS Nevada Test Site
OEF Operation Enduring Freedom
OEH Occupational and environmental health
OEHHA Office of Environmental Health Hazard Assessment
OEHS Occupational environmental health and safety
OEL Occupational exposure limit
OGC Office of the General Counsel
OH Occupational health
OHMIS Occupational Health Management Information System
OIF Operation Iraqi Freedom
OMB Office of Management and Budget
OPHEH Office of Public Health and Environmental Hazards
OPM Office of Personnel Management
OR Odds ratio
ORCON Originator controlled dissemination and extraction of information
ORD Office of Research and Development
OSHA Occupational Safety and Health Administration
OSTP Office of Science and Technology Policy
PAF Population attributable fraction
PAR Population attributable risk
PC Probability of causation
PCB Polychlorinated biphenyl
PDDM Presumptive disability decision making
PHA Periodic health assessment
PKDL Post-kala-azar dermal leishmaniasis
PL Public Law
POM Program Objectives Memorandum
POW Prisoner of War
PPB Parts per billion
PPG Pacific Proving Grounds
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PPM Parts per million
PPV Positive predictive value
PSA Prostate-specific antigen
PSG II Professional Staffing Group II
PTF Presidential Task Force
PTSD Posttraumatic stress disorder
PY Person-year
RADS Reactive airways dysfunction syndrome
RCT Randomized controlled/clinical trial
RD Restricted data
ReA Reactive arthritis
RECA Radiation Exposure Compensation Act of 1990
RECAC Radiation Exposure Compensation Act Committee
REVCA Radiation-Exposed Veterans Compensation Act
RO Rey-Osterreith Test
ROC Receiver Operator Characteristics curve
RR Relative risk/risk ratio
RTI Research Triangle Institute
SAD Service-attributable disease
SAF Service-attributable fraction
SANG Saudi Arabian National Guard
SAP Special Access Program
SCI Sensitive Compartmented Information
SCID Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders
SCL Symptoms Checklist
SEER Surveillance Epidemiology and End Results
SEG Similar exposure group
SES Socioeconomic status
SF Standard Form
SFFWG Shared Functions Focus Working Group
SHAD Project Shipboard Hazard and Defense
SMITREC Serious Mental Illness Treatment Research and Evaluation Center
SMR Standardized mortality ratio
SSA Social Security Administration
SSDI Social Security Disability Insurance
SSI Supplemental Security Income
TBI Traumatic brain injury
TCDD Tetrachlorodibenzo-p-dioxin
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TN True negative
TNR True negative rate
TP True positive
TPR True positive rate
UNSCEAR United Nations Scientific Committee on the Effects of Atomic Radiation
USC United States Code
USPSTF U.S. Preventive Health Services Task Force
VA Department of Veterans Affairs
VAO Veterans and Agent Orange
VASRD Veterans Administration Schedule for Rating Disabilities
VBA Veterans Benefits Administration
VDBC Veterans’ Disability Benefits Commission
VDRECSA Veterans’ Dioxin and Radiation Exposure Compensation Standards Act
VES Vietnam Experience Study
VET (registry) Vietnam Era Twin (registry)
VHA Veterans Health Administration
VHI Veterans Health Initiative
VISTA Veterans Health Information Systems and Technology Architecture
VOC Volatile organic compound
VSO Veterans Service Organization
WAIS-R Wechsler Adult Intelligence Scale-Revised
WNINTEL Warning notice, intelligence sources, and methods involved
WRIISC War-Related Illness and Injury Study Centers
WWI World War I
WWII World War II
YLD Years of life lived with disability
YLL Years of life lost
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